(BQ) Part 1 book “Principles of deformity correction” has contents: Normal lower limb alignment and joint orientation; malalignment and malorientation in the frontal plane, sagittal plane deformities, osteotomy concepts and frontal plane realignment, oblique plane deformities,… and other contents.
DROR PALEY PRINCIPLES OF DEFORMITY CORRECTION Springer-Verlag Berlin Heidelberg GmbH DROR PALEY PRINCIPLES OF EFOR M I TV CORRECTION With Editorial Assistance from J E Herzenberg With More Than 1,800 Separate Illustrations, Clinical Photographs, and Radiographs i Springer DROR PALEY,MD,FRCSC Director, Rubin Institute for Advanced Orthopedics Sinai Hospital Co-Director, The International Center for Limb Lengthening, Sinai Hospital Baltimore, MD Present address: Rubin Institute for Advanced Orthopedics Sinai Hospital 2401 West Belvedere Avenue Baltimore, Maryland 21215-5271, USA E-mail: dpaley@lifebridgehealth.org www.limblengthening.org www.deformitycourse.com ISBN 978-3-642-63953-1 ISBN 978-3-642-59373-4 (eBook) DOI 10.1007/978-3-642-59373-4 1st ed 2002 Corr 3rd printing 2005 CIP-data applied for Die Deutsche Bibliothek- CIP-Einheitsaufnahme Paley, Dror: Principles of deformity correction Dror Paley.Berlin; Heidelberg; New York; Barcelona; Hongkong; London ; Mailand ; Paris ; Singapur ; Tokio : Springer, 2002 This work is subject to copyright Ali rights are reserved, whether the whole or part of the material is concerned, specifically the rights of translation, reprinting, reuse of illustrations, recitation, broadcasting, reproduction on microfilm or in any other way, and storage in data banks Duplication of this publication or parts thereof is permitted only under the provisions of the German Copyright Law of September 9, 1965, in its current version, and permission for use must always be obtained from Springer-Verlag Violations are liable for prosecution under the German Copyright Law http:/ /www.springer.de © Springer-Verlag Berlin Heidelberg 2002 Originally published by Springer-Verlag Berlin Heidelberg New York in 2002 Softcover reprint of the hardcover 1st edition 2002 The use of general descriptive names, registered names, trademarks, etc in this publication does not imply, even in the absence of a specific statement, that such names are exempt from the relevant protective laws and regulations and therefore free for general use Product liability: The publishers cannot guarantee the accuracy of any information about dosage and application contained in this book In every individual case the user must check such information by consulting the relevant literature Cover design: E Kirchner, Heidelberg Product management and layout: B Wieland, Heidelberg Typesetting and production: AM-production, Wiesloch 24/3150-5 o Printed on acid-free paper ~ This book is dedicated to the memory of my father, Zvi Paley, who gave so much and asked for so little - Foreword What is genius? Analyzing complex problems and finding simple ways to explain them in an understandable manner By this definition, this book is genius The most dramatic progress in orthopaedic surgery during the last decades has been in the field of deformity correction The treatment of deformities has occupied and challenged orthopaedic surgeons since Nicholas Andry So many brilliant people have worked in this field Among them, Friedrich Pauwel and Gavril Ilizarov should be individually named Dr Ilizarov developed new methods oflimb lengthening and deformity correction and sparked the newfound interest and developments in this field today In Dror Paley, this spark became a raging fire Dr Paley inaugurated many innovations in the field of deformity correction Among them, his nomenclature deserves special mention Before his classification based on joint orientation, we had a plethora of confusing terminology and definitions leading to a confusion of language reminiscent of the Tower of Babel Dr Paley's nomenclature standardizes the terminology in a manner that requires little memorization This logically based system has gained international recognition and acceptance as the single language of deformity analysis and correction This book presents us with these concepts The principles and concepts outlined in this book were not discovered or understood overnight They represent an evolution of Dr Paley's ideas from the past 14 years of clinical work in the field of deformity correction Unlike other texts, which come and go because they are technique-centric, this tome is principle-based and will therefore stand the test of time The limb lengthening and deformity reconstruction center created by Drs Paley and Herzenberg in Baltimore is not only the clinical laboratory where this deformity correction work was developed and understood but has also become the Mecca for students in this medical specialty, with visitors from allover the world traveling to learn firsthand from these masters of deformity correction It is in this manner that I first became exposed to the CORA method of mechanical and anatomic axis planning This has resulted in a long-standing collaboration between our two facilities, centered on our common interest in this subspecialty We routinely apply these principles to deformity correction at our center in Germany Many of the new deformity correction devices that I and others are designing are now based on the CORA principles Dr Paley'S deformity correction courses around the world have popularized the planning methods and principles espoused in this book The annual Baltimore Limb Deformity Course is the foundation for this book, workbook, and CD Each of its chapters has been presented as lectures at this course, and the workbook and multimedia CD have been tested by live audiences at these courses for many years I am sure this book will become the bible for the understanding, diagnosis, and treatment of lower limb deformities Wiesbaden, Germany JOACHIM PFEIL Preface My prediction: this book will become a classic Brave words, but I can safely make this statement because this book is not about the latest surgical operation or about our knowledge of certain pathologies, which is constant1y changing Rather, this book presents a system of deformity analysis that is universal and applicable to any past, current, or future surgical osteotomy techniques and hardware One needs only to think back to medical school and realize that most of the textbooks that we so carefully studied are now "of historic interest only:' Grant's Atlas of Anatomy is perhaps the only book from my medical school days that I still use I predict that Paley's Principles of Deformity Correction will also have a long shelflife The treatment of skeletal deformity is the heart of our specialty Indeed, the very name of our specialty, orthopaedics, was coined by Nicholas Andry in 1741 as a word derived from two Greek words, orthos (meaning straight) and paedis (meaning child) to indicate his goal "to teach the different methods of preventing and correcting deformities of children" (from Mercer Rang's Anthology of Orthopaedics, 1966) Since Andry's writings 260 years ago, little progress has been made in understanding, analyzing, and quantifying the types of limb deformities Rarely we come across an orthopaedic surgeon who is truly an artist (or sculptor) Such an individual does not require accurate preoperative planning to execute a flawless corrective osteotomy However, for the rest of us journeymen orthopaedic surgeons, achieving such beautiful artistic and aesthetic outcomes is elusive We tend to take a wedge here or there, by eyeball estimation, and then rationalize the less than perfect appearance of the final X-ray "It's not bad" or "it should remodel:' True, there have been attempts by notable surgeons, such as Friedrich Pauwels and Maurice Mueller, to be more precise in our planning Although we may have received training in the precise repositioning of fracture fragments with plates and screws and accurate preoperative planning and templating for hip osteotomies, what has eluded us until now is a universally applicable lower extremity deformity planning system that takes into account the entire limb, including associated joint compensation and lever arm considerations: a unified or universal system that is equally applicable to the diverse range of ages and pathological abnormalities that come under the purview of the adult and pediatric orthopaedist It has been my privilege and honor to be associated professionally with Dr Dror Paley for the past 10 years, and I probably know him better than anyone else does I have therefore been in a unique position to observe how he developed the CORA method and to contribute as a co-developer, editor, and author Dr Paley has an uncanny knack of clearly seeing and understanding orthopaedic deformities More importantly, he has a unique ability to then process and integrate this information to make it accessible to the less clairvoyant We have striven to make this method practical and teachable It is not hard to learn, but it does take some effort and practice The method is mercifully low-tech: the only tools required are a pencil, ruler, and goniometer We have honed our ability to teach this method during the past 10 years at our annual Baltimore Limb Deformity Course, and many of the figures and cases illustrated in this book have been used in the course The case studies and the artists' diagrams are all derived from our own practices and are representative of deformities that we have treated In this regard, we are greatly indebted to our patients for providing us with both typical and atypical problems to study and illustrate Interestingly, the CORA method of deformity analysis began simply as an attempt to make some sense of the Ilizarov apparatus As the orthopaedic surgeon who introduced this method in Canada and the USA, Dr Paley struggled to understand the concept of the Ilizarov hinge, which is what made the Ilizarov fixator so unique in its ability to correct deformities in a controlled fashion In his early experience, he observed some of the secondary deformities that arose from mismatching the location of the hinge and the CORA In his effort to more accurately identify the level for the Ilizarov hinge, he derived the CORA method of mechanical and anatomic axis planning described in this text He quickly realized that the concept of the CORA and the osteotomy rules were not unique to the Ilizarov device but much more universally applicable to deformity correction by any method Indeed, with the CORA method, one can understand and plan surgery for any lower extremity deformity from the hip to the foot The gener- al principle of this book is to first analyze, understand, and quantify the deformity Only then should you begin to plan your surgical method and approach Regardless of which type and brand of fixation is selected (plates, rods, or external fixator), the basic principles of deformity analysis and planning are the same Failure to observe these principles frequently results in less than perfect alignment and often in secondary deformities that may be more difficult to correct than the original deformities Ultimately, the surgeon must decide which device works best in his or her hands The first step of preoperative planning, however, is universally required and beneficial Chap 11 includes a discussion of some of the vagaries of selected hardware devices, and it is this chapter that will most likely require updating and revision in a future edition as new device innovations become available The bulk of the book, however, encompasses principles and concepts that will not change because they are based on simple geometry Will the CORA method be supplanted by future technology? We think not Even computer-dependent mathematical modeling of six-axis deformity correction (see Chap 12) is first dependent on the surgeon to accurately understand, analyze, and quantify the radiographic deformity We therefore think that the CORA method complements rather than competes with such sophisticated deformity correction methods Is this book the final word on the topic? Clearly not The CORA method is still a work in progress, and there is room to extend its application to the upper extremity, spine, pelvis, and perhaps even maxillofacial deformity correction It has recently been incorporated into computer planning software This book has already been lO years in the making, and these other expansions will have to wait for the second edition We welcome readers' comments, criticisms, and feedback to help us improve future editions Baltimore, Maryland JOHN E HERZENBERG The Story Behind This Book and the CORA Method My first exposure to orthopaedics was as a medical student learning physical examination My patient had a severe limp, which I attributed to weakness of his gluteus medius What today I would recognize as an obvious Trendelenburg's gait, in 1977 was the pivotal event that sparked my interest in orthopaedic surgery I began to read the works of Rene Caillet (The Biomechanics of Joints) and of LA Kapandji (Physiology ofJoints) Their books made human mechanics easy to comprehend, even for a medical student With Principles of Deformity Correction, I attempt to the same regarding deformity analysis and treatment I am grateful to the many great teachers from my ortho- paedic residency at the University of Toronto They laid the foundation for my interest in orthopaedics Professor Robert Salter set the tone, teaching in a Socratic manner Dr Alan Gross of Mt Sinai Hospital first taught me the concept of the mechanical axis of the lower limb as well as the importance of preoperative planning for osteotomies of the hip and knee He frequently quoted Renato Bombelli's Osteoarthritis of the Hip: Classification and Pathogenesis - The Role of Osteotomy as a Consequent Therapy (Springer-Verlag, 1983) and Paul Maquet's Biomechanics of the Knee: With Application to the Pathogenesis and the Surgical Treatment of Osteoarthritis (Springer-Verlag, 1984), which stimulated me to read these books on the biomechanics of the hip and knee, respectively Drs David MacIntosh and Ian Harrington taught me controversial concepts of high tibial osteotomies and alignment Dr Harrington's book on biomechanics (Biomechanics of Musculoskeletal Injury; Williams & Wilkins, 1982) and his often misunderstood article on high tibial osteotomy UBJS 65(2):247-259, 1983] greatly influenced my understanding of concepts in this field Drs Marvin Tile, Joseph Schatzker, Robert McMurtry, and James Kellam are responsible for teaching me to think in terms of universal principles rather than specific surgical techniques Principles to orthopaedics are like laws to physics: they remain constant, whereas specific operations and techniques come and go The widest spectrum and complexity of deformity occur in pediatric orthopaedics in that many conditions - affect the growth and development of the skeleton My teachers at the Hospital for Sick Children, Drs Norris Carroll, Colin Moseley, Mercer Rang, Walter Bobechko, Robert Gillespie, and Robert Salter, provided my initial exposure and understanding of the growth plate and the pediatric skeleton The training I received from them during my residency and fellowship prepared me to challenge many well-established practices and beliefs in pediatric orthopaedics Of all these, I received the greatest support from Dr Norris Caroll, who always had faith in me and invested his time and patience to teach me meticulous surgical technique and who encouraged me at times of despair I acknowledge the support of two of pediatric orthopaedics' elder statesmen, Drs Lynn Staheli and Mihran Tachdjian Dr Staheli, as editor of the Journal of Pediatric Orthopedics, invited me to write about current techniques of limb lengthening in 1988 UPO 8:73-92, 1988) and more recently to write an editorial on deformity correction in the twenty-first century UPO 20:279-281, 2000) Both of these publications helped introduce and heighten awareness to deformity correction principles The late Dr Tachdjian involved me in his internationally renowned pediatric orthopaedic review course since 1988 and included my deformity planning method in his textbooks (Pediatric Orthopedics, 1990; and Atlas of Pediatric Orthopedic Surgery, 1994) Dr Charles Price, who took over this pediatric course, has included deformity planning by the CORA method as an important theme of the new course In November 1983, when I was a third-year orthopaedic resident in Toronto, I met Renato Bombelli who was a visiting professor Dr Bombelli was a disciple of Friedrich Pauwels and a contemporary of Maquet, another of Dr Pauwels' disciples Through their writings, I began to understand that complicated joint mechanics could be reduced to simple principles While in Toronto, Dr Bombelli briefly mentioned the Ilizarov method This offhand comment sparked my interest in a field totally unknown in North America Upon completing my residency in 1985, I visited Dr Maurizio Catagni in Italy to learn more about the Ilizarov method The next year, I took my family to Europe and spent months in Italy and the USSR studying limb reconstruction with exter- m CHAPTER 11 · Hardware and Osteotomy (onsiderations ~ K-wire b a A lncisions L M p d CHAPTER 11 · HardwareandOsteotomyConsiderations i j k t 111 m CHAPTER 11 · Hardware and Osteotomy Considerations j Fig 11·70 a-m ~ Percutaneous Gigli saw osteotomy of the distal tibia Note that the Gigli saw technique should be avoided where there is thick diaphyseal cortical bone a-g Two transverse incisions are made, and a suture is passed subperiosteally from anterolateral to posteromedial using a right angle and a curved clamp (This direction is opposite that used for the proximal tibia) A,Anterior; P, posterior; M, medial; L, lateral h, i The Gigli saw is tied to the suture and is pulled through from anterior to posterior The posterior and lateral cortices and the medullary canal are cut with the saw under the protection of two elevators k The medial cortex periosteuro is then elevated and the medial cortex cut by fiattening out the direction of the pull of the saw l,m The saw is then cut and pulled out CHAPTER 11 · HardwareandOsteotomyConsiderations a L p lncisions m m CHAPTER 11 · Hardware and Osteotomy Considerations k CHAPTER 11 · HardwareandOsteotomyConsiderations ll!lll a b A d L M lncisions p e Fig 11-71 a-j Percutaneous Gigli saw osteotomy in the supramalleolar region of the tibia and fibula At this Ievel, there is no space between the tibia and the fibula through which to pass a suture Both the tibia and the fibula are cut together, and the Gigli saw is passed araund both bones a, b Three small incisions are used The two medial incisions are transverse, and the lateral incision is longitudinal A, Anterior; P, posterior; M, medial; L, lateral c The periosteum on the anterior aspect of the tibia and fibula is elevated From the anteromedial side, the fibular incision is made over the tip of the protruding elevator over the fibula d A long curved clamp is used to pass a suture from antero- medial to the lateral side e The Gigli saw is tied to the suture and pulled through from medial to lateral f, g The periosteum is elevated on the posterior side of the tibia and fibula and the suture passed from the lateral incision to the posteromedial one h The Gigli saw is pulled through to the posteromedial side i,j The medial periosteum is elevated,and the Gigli saw is used to cut the fibula and tibia from lateral to medial The saw is then cut and removed ID CHAPTER 11 · Hardware and Osteotomy Considerations a b K-wire ~ K-wire ~ L M c e h f g j i J CHAPTER 11 · Hardware and Osteotomy Considerations L _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ _ k I lmll m Fig 11-72 a-m Percutaneous Gigli saw osteotomy of the proximal femur This method is especially useful for cutting the medial cortex only of the femur when an intramedullary saw is already in place For breaking the entire femur, the multiple drill hole and osteotome technique is much easier, faster, and less traumatic a, b Two lateral transverse incisions are made to pass the Gigli saw A, Anterior; P, posterior; M, medial; L, lateral c The periosteum is elevated from the lateral side, both posterior and anterior to the femur d-f Using a right angle clamp and a long curved clamp, a suture is passed around the femur subperiosteally g,h The Gigli saw is tied to the suture and passed around the femur i,j The femur is cut from medial to lateral with the Gigli saw k This method is mostly used to cut the hone around an IMN The Gigli saw is passed around the diaphysis of the femur, as shown in Fig ll-72a-h The Gigli saw can cut the medial cortex until it comes in contact with the IMN m The Gigli saw is removed, and the remaining cortices are cut with a narrow osteotomy IB CHAPTER 11 · Hardware and Osteotomy Considerations a K-wire ~ L M p c d g CHAPTER 11 · HardwareandOsteotomyConsiderations i h m j k Fig 11-73 a-1 Percutaneous Gigli saw osteotomy of the distal femur This osteotomy is rarely indicated hecause the multiple drill hole and osteotome technique is more easily performed a Two transverse small incisions are used: one anteromedial and one posterolateral b The location of the cortex is found using K-wires and the incisions made at that point A, Anterior; P, posterior; M, medial; L, lateral c The periosteum is elevated posteriorly and medially d A right angle clamp is used to make space for passage of the suture e-g Using a right angle clamp and a long curved clamp, a suture is passed around the femur from posterolateral to anteromedial h, i The Gigli saw is tied to the suture and pulled around the fernur Only the posterior and medial cortices can he cut with the saw Further cutting will darnage the quadriceps muscle and tendon k, I An osteotome is used to complete the hone cut The osteotome can he twisted to crack the hone m CHAPTER 11 Hardware and Osteotomy Considerations a b c j d Fig.11-74 a-h Percutaneous inclined Gigli saw osteotomy a A K-wire is driven at the desired inclined angle b One incision is made at the proximal end and one at the distal end of the wire Periosteal elevation is performed at each end Laterally, the elevation is anteroposterior, whereas posteromedially, the elevation follows the K-wire to meet the lateral dissection c A suture is passed through the two incisions by using the method previously shown in Fig 11-69 The only difference is that the passage follows an oblique rather than a transverse course between the two incisions d The Gigli saw is pulled through the incisions and passed around the tibia e The Gigli saw is kept distal to the K-wire proximally and laterally and proximal to the K-wire distally and posteromedially f The K-wire guides the cut with the saw The medial cortex periosteum is elevated along the inclined path h The medial cortex is then cut with the saw and the Gigli saw cut and removed CHAPTER 11 Hardware and Osteotomy Considerations _ m CHAPTER 11 Hardware and Osteotomy Considerations a c 3rd Incision Dorsal /,P ~ 1' 4Ih Incision I 1sl Incisi on 2nd Incision L CHAPTER 11 Hardware and Osteotomy Considerations j m k ~====d ~ I n Fig 11-75 a-n Percutaneous Gigli saw osteotomy of the midfoot a, b There are three levels in the midfoot at which a Gigli saw can be safely passed percutaneously: the talocalcaneal neck, cuboid-navicular, and cuboid cuneiform bones Four small incisions are used to pass the saw: medial, lateral, and two dorsal incisions c,d Because of the concavity of the transverse arch and the multiple bones present, the plantar periosteal elevation often weaves in and out of the subperiosteal space M, Medial; L, lateral e A suture is passed from lateral to medial (the reverse can also be done) The Gigli saw is passed from lateral to medial under the foot Through a third incision, which is made on the dorsomedial aspect of the foot, the suture and Gigli saw are passed to the dorsum of the foot h A fourth incision is made on the dorsolateral side and the periosteum elevated on the dorsum of the foot The suture and Gigli saw are passed around the foot from plantar to dorsal, exiting on the dorsolateral side opposite the entrance site on the plantar lateral side j, k Under the protection of periosteal elevators, the bone is cut by the saw I The lateral periosteal bridge is elevated, and the most lateral part of the bone is cut m, n The saw is cut and removed HardwMe and Osteotomy Considerations Astion DJ, Wilber JH, Scoles PV (1995) Avascular necrosis of the capital femoral epiphysis after intramedullary nailing for a fracture of the femoral shaft: A case report J Bone Joint SurgAm 77:lO92-lO94 Collinge CA, Sanders RW (2000) Percutaneous plating in the lower extremity J Am Acad Orthop Surg 8:211-216 Gladbach B, Pfeil J, Heijens E (1999) Deformitatenkorrektur des Beins: Definition, Quantifizierung, Korrektur der Translationsfehlstellung und Durchfiihrung von Translationsvorgaben Orthopade 28:lO23-lO33 Herzenberg JE, Paley D (1997 a) Femoral lengthening over nails (LON) Tech Orthop 12:240-249 Herzenberg JE, Paley D (1997b) Tibial lengthening over nails (LON) Tech Orthop 12:250-259 Herzenberg JE, Waanders NA (1991) Calculating rate and duration of distraction for deformity correction with the Ilizarov technique Orthop Clin North Am 22:601-61 Herzenberg JE, Smith JD, Paley D (1994) Correcting torsional deformities with Ilizarov's apparatus Clin Orthop 302:3641 Krackow KA (1983) Approaches to planning lower extremity alignment for total knee arthroplasty and osteotomy about the knee Adv Orthop Surg 7:69-88 Paley D (1989) The principles of deformity correction by the Ilizarov technique: technical aspects Tech Orthop 4:15-29 Paley D, Herzenberg JE, Paremain G, Bhave A (1997) Femoral lengthening over an intramedullary nail: a matched-case comparison with Ilizarov femoral lengthening J Bone Joint Surg Am 79:1464-1480 Paley D, Tetsworth K (1991) Percutaneous osteotomies: Osteotome and Gigli saw techniques Orthop Clin North Am 22:613-624 Paley D, Tetsworth K (1993) Deformity correction by the Ilizarov technique In: Chapman MW (ed) Operative orthopaedics, vol 1, 2nd edn J.B Lippincott, Philadelphia, pp 883-948 Scheffer MM, Peterson HA (1994) Opening-wedge osteotomy for angular deformities of long bones in children J Bone Joint Surg Am 76:325-334 Tetsworth KT, Paley D (1994) Accuracy of correction of complex lower extremity deformities by the Ilizarov method Clin Orthop 301:lO2-110 ... 31 Ankle and Hip 40 Radiographic Examination in the Sagittal Plane 46 Knee 46 Ankle 51 61 63 99 10 1 10 1 10 2 10 5 10 6 10 6 Focal... Planning ofTibial Deformity Correction Sagittal Plane Anatomic Axis Planning of Femoral Deformity Correction Osteotomies in the Sagittal Plane References 15 9 16 3 16 3 16 5 16 5 16 9 16 9... Less Than 90° Apart Oblique Plane Deformity with Angulation and Translation Less Than 90° Apart 211 214 216 218 Osteotomy Correction of a-t Deformities Osteotomy Correction of Angulation and